THIS IS AN APPLICATION ONLY AND DOES NOT CONSTITUTE OR IMPLY ANY INSURANCE COVERAGE IS IN FORCE.
Where (a) an Applicant for this contract gives false particulars to the prejudice of the insurer or knowingly misrepresents or fails to disclose any
fact in any part of this application required to be stated therein; or (b) the insured contravenes a term of the contract or commits a fraud; or (c)
the insured willfully makes a false statement in respect of a claim, a claim will become invalid and the Insured’s right to recovery is forfeited.
The Applicants have reviewed contents of this application and acknowledge that all the information is true and correct and understand that this
application for insurance is based on the truth and completeness of this information.
I have provided personal information in this document and otherwise and I may in the future provide further personal information. Some of this
personal information may include, but is not limited to, my credit information and claims history. I authorize my broker or insurance company
to collect, use and disclose any of this personal information, subject to the law and to my broker’s or insurance company’s policy regarding
personal information, for the purposes of communicating with me, assessing my application for insurance and underwriting my policies,
evaluating claims, detecting and preventing fraud, and analyzing business results. I confirm that all individuals whose personal information is
contained in this document have authorized that I agree to the above on their behalf.